Healthcare Provider Details

I. General information

NPI: 1003444191
Provider Name (Legal Business Name): RACHAEL MARIE CANNON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 SW 24TH AVE APT 323
GAINESVILLE FL
32607-4470
US

IV. Provider business mailing address

3950 SW 24TH AVE APT 323
GAINESVILLE FL
32607-4470
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-8234
  • Fax:
Mailing address:
  • Phone: 814-574-2554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number161549
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number161549
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number161549
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: